Binostril versus mononostril approaches in endoscopic transsphenoidal pituitary surgery: clinical evaluation and cadaver study

OBJECTIVE Over the past 2 decades, endoscopy has become an integral part of the surgical repertoire for skull base procedures. The present clinical evaluation and cadaver study compare binostril and mononostril endoscopic transnasal approaches and the surgical techniques involved. METHODS Forty patients with pituitary adenomas were treated with either binostril or mononostril endoscopic surgery. Neurosurgical, endocrinological, ophthalmological, and neuroradiological examinations were performed. Ten cadaver specimens were prepared, and surgical aspects of the preparation and neuroradiological examination were documented. RESULTS In the clinical evaluation, 0° optics were optimal in the nasal and sphenoidal phase of surgery for both techniques. For detection of tumor remnants, 30° optics were superior. The binostril approach was significantly more time consuming than the mononostril technique. The nasal retractor limited maneuverability of instruments during mononostril approaches in 5 of 20 patients. Endocrinological pituitary function, control of excessive hormone secretion, ophthalmological outcome, residual tumor, and rates of adverse events, such as CSF leaks and diabetes insipidus, were similar in both groups. In the cadaver study, there was no significant difference in the time required for dissection via the binostril or mononostril technique. The panoramic view was superior in the binostril group; this was due to the possibility of wider opening of the sella in the craniocaudal and horizontal directions, but the need for removal of more of the nasal septum was disadvantageous. CONCLUSIONS Because of maneuverability of instruments and a wider view in the sphenoid sinus, the binostril technique is superior for resection of large tumors with parasellar and suprasellar expansion and tumors requiring extended approaches. The mononostril technique is preferable for tumors with limited extension in the intra- and suprasellar area.

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4K 3-dimensional video microscope system (orbeye) for transsphenoidal pituitary surgery

Acta Neurochirurgica ◽

10.1007/s00701-021-04762-x ◽

2021 ◽

Author(s):

Roman Rotermund ◽

Jan Regelsberger ◽

Katharina Osterhage ◽

Jens Aberle ◽

Jörg Flitsch

Keyword(s):

3D Visualization ◽

Remission Rate ◽

Subjective Evaluation ◽

Pituitary Surgery ◽

Image Resolution ◽

Wide Range ◽

Significant Difference ◽

Duration Of Surgery ◽

Video Microscope ◽

Transsphenoidal Pituitary Surgery

Abstract Background In previous reports on experiences with an exoscope, this new technology was not found to be applicable for transsphenoidal pituitary surgery. As a specialized center for pituitary surgery, we were using a 4K 3D video microscope (Orbeye, Olympus) to evaluate the system for its use in transsphenoidal pituitary surgery in comparison to conventional microscopy. Method We report on 296 cases performed with the Orbeye at a single institution. An observational study was conducted with standardized subjective evaluation by the surgeons after each procedure. An objective measurement was added to compare the exoscopic and microscopic methods, involving surgery time and the initial postoperative remission rate in matched cohorts. Results The patients presented with a wide range of pathologies. No serious events or minor complications occurred based on the usage of the 4K 3D exoscope. There was no need for switching back to the microscope in any of the cases. Compared to our microsurgically operated collective, there was no significant difference regarding duration of surgery, complications, or extent of resection. The surgeons rated the Orbeye beneficial in regard to instrument size, positioning, surgeon’s ergonomics, learning curve, image resolution, and high magnification. Conclusions The Orbeye exoscope presents with optical and digital zoom options as well as a 4K image resolution and 3D visualization resulting in better depth perception and flexibility in comparison to the microscope. Split screen mode offers the complementary benefit of the endoscope which may increase the possibilities of lateral view but has to be evaluated in comparison to endoscopic transsphenoidal procedures in the next step.

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Integration of Early Postoperative MRI Increases Diagnostic Confidence and Concordance for Detection of Residual Tumor after Transsphenoidal Pituitary Surgery

10.1055/s-0039-1679535 ◽

2019 ◽

Author(s):

Jae Lee ◽

Lea Alhilali ◽

Corbin Stephens ◽

William White

Keyword(s):

Residual Tumor ◽

Pituitary Surgery ◽

Diagnostic Confidence ◽

Postoperative Mri ◽

Transsphenoidal Pituitary Surgery

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Case Report: Persistent Acromegaly – Effective Therapy with Lanreotide and Weekly Pegvisomant Injections

Experimental and Clinical Endocrinology & Diabetes Reports ◽

10.1055/a-0630-0412 ◽

2018 ◽

Vol 05 (01) ◽

pp. e9-e12 ◽

Cited By ~ 1

Author(s):

Thomas Schürmeyer ◽

Britta Galling

Keyword(s):

Growth Hormone ◽

Hormone Secretion ◽

Growth Hormone Secretion ◽

Residual Tumor ◽

Pituitary Surgery ◽

Effective Therapy ◽

Somatostatin Analog ◽

Endocrine Control ◽

Insulin Growth Factor ◽

Pre Treatment

Abstract Objective Therapeutic options for persistent acromegaly after surgery include another surgical approach, radiotherapy, medical therapy or a combination of these procedures. We describe a patient with persistent acromegaly despite heavy pre-treatment who was in need of a simplified mode of effective therapy. Methods In a 45-year old patient after transsphenoidal pituitary surgery followed by linear accelerator irradiation of the residual tumor two years later acromegaly could not be controlled by a tolerable dosage of intramuscular octreotide LAR. For professional reasons the patient requested a simplified mode of treatment. Results In order to improve efficacy and treatment convenience, we combined subcutaneous injections of lanreotide up to 120 mg monthly performed by the patient’s spouse and of pegvisomant 80 mg weekly conducted by the patient himself. This therapy was well tolerated and satisfactory endocrine control was achieved. Magnetic resonance imaging did not show any remaining tumor within a year. 5 years following surgery and 3 years following irradiation pegvisomant could be stopped and levels of insulin growth factor 1 and growth hormone remained in the normal range. The interval of lanreotide given subcutaneously by the patient’s spouse could be extended stepwise and somatostatin analog treatment was terminated after 7.5 years when the patient was cured. Conclusions Excessive growth hormone secretion persisting after pituitary surgery and irradiation can be controlled in a convenient way for the patient with acromegaly by combining monthly lanreotide and weekly pegvisomant injections, if monotherapy with a somatostatin analog fails.

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Ten years’ experience with intraoperative MRI-assisted transsphenoidal pituitary surgery

Neurosurgical FOCUS ◽

10.3171/2020.3.focus2072 ◽

2020 ◽

Vol 48 (6) ◽

pp. E14

Author(s):

Michal Hlaváč ◽

Andreas Knoll ◽

Benjamin Mayer ◽

Michael Braun ◽

Georg Karpel-Massler ◽

...

Keyword(s):

Pituitary Adenomas ◽

Cox Regression ◽

Tumor Resection ◽

Residual Tumor ◽

Pituitary Surgery ◽

Intraoperative Mri ◽

Target Tissue ◽

Cox Regression Analysis ◽

Transsphenoidal Pituitary Surgery ◽

Additional Resection

OBJECTIVEMany innovations have been introduced into pituitary surgery in the quest to maximize the extent of tumor resection. Because of the deep and narrow surgical corridor as well as the heterogeneity of confronted pathologies, anatomical orientation and identification of the target tissue can become difficult. Intraoperative MRI (iMRI) may have the potential to increase extent of resection (EOR) in transsphenoidal pituitary surgery. Furthermore, it may simplify anatomical orientation and risk assessment in difficult cases. Here, the authors evaluated the additional value of iMRI for the resection of pituitary adenomas performed in the past 10 years in their department.METHODSThey performed a retrospective single-center analysis of patients treated for pituitary adenoma in their department after the introduction of iMRI between 2008 and 2018. Of 495 transsphenoidal approaches, 300 consecutive MRI-assisted surgeries for pituitary adenomas encompassing 294 patients were selected for further analysis. Microscopic, endoscopic, or endoscope-assisted microscopic transsphenoidal approaches were distinguished. EOR as well as additional resection following iMRI was evaluated via detailed volumetric analysis. Patients were stratified according to the Knosp adenoma classification. Furthermore, demographic data, clinical symptoms, endocrine outcome, and complications were evaluated. Univariable and multivariable Cox regression analyses of progression-free survival (PFS) were performed.RESULTSPituitary adenomas classified as Knosp grades 0–2 were found in 60.3% of cases (n = 181). The most common tumors were nonfunctioning adenomas (75%). Continued resection following iMRI significantly increased EOR (7.5%, p < 0.001) and the proportion of gross-total resections (GTRs) in transsphenoidal pituitary surgery (54% vs 68.3%, p < 0.001). Additional resection after iMRI was performed in 37% of cases. Only in the subgroup of patients with Knosp grades 0–2 adenomas treated with the microsurgical technique was additional resection significantly more common than in the endoscopic group (p = 0.039). Residual tumor volume, Knosp grade, and age were confirmed as independent predictors of PFS (p < 0.001, p = 0.021, and p = 0.029, respectively) in a multivariable Cox regression analysis. Improvement of visual field deficits was documented in 78.6% of patients whose optic apparatus had been affected preoperatively. Revision surgery was done in 7.3% of cases; in 5.6% of cases, it was performed for cerebrospinal fluid fistula.CONCLUSIONSIn this series, iMRI led to the detection of a resectable tumor remnant in a high proportion of patients, resulting in a greater EOR and higher proportion of GTRs after continued resection in microsurgical and endoscopic transsphenoidal resection of pituitary adenomas. The volume of residual tumor was the most important predictor of PFS. Given the study data, the authors postulated that every bit of removed tumor serves the patient and increases their chances of a favorable outcome.

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Endoscopic transsphenoidal pituitary surgery: various surgical techniques and recommended steps for procedural transition

British Journal of Neurosurgery ◽

10.1080/02688690050175229 ◽

2000 ◽

Vol 14 (5) ◽

pp. 432-440 ◽

Cited By ~ 40

Author(s):

H-D. Jho, A. Alfieri

Keyword(s):

Surgical Techniques ◽

Pituitary Surgery ◽

Transsphenoidal Pituitary Surgery

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Impact of Endoscopic Surgical Techniques on Efficiency in Pituitary Surgery

Otolaryngology ◽

10.1177/0194599811416753 ◽

2011 ◽

Vol 145 (5) ◽

pp. 732-736 ◽

Cited By ~ 5

Author(s):

Brett T. Comer ◽

A. Byron Young ◽

Thomas J. Gal

Keyword(s):

Operating Room ◽

Univariate Analysis ◽

Surgical Techniques ◽

Case Series ◽

Pituitary Surgery ◽

Setup Time ◽

Tertiary Referral Center ◽

Endoscopic Techniques ◽

Transsphenoidal Pituitary Surgery ◽

The Impact

Objective. To assess the impact of the introduction of endoscopic surgical techniques into a neurosurgical practice for pituitary surgery on operative efficiency. Study Design. Case series with chart review. Setting. Tertiary referral center. Subjects and Methods. Patients undergoing transsphenoidal pituitary surgery over a 4-year period were identified. The approach over this period evolved from classic transseptal surgery to exclusively endoscopic techniques. Patients were classified as having transseptal surgery, endoscopic approach with microsurgical resection, aborted endoscopic resection with subsequent microsurgery, and exclusive endoscopic techniques. Patient and surgeon demographics, operative times, total operating room times, and room setup time were examined. Univariate analysis and multivariate regression modeling were used to assess outcome measures. Results. One hundred seven patients were identified. The use of the endoscope for either sphenoid exposure alone (n = 41) or for the entire procedure (n = 35) resulted in a significant reduction in operative and room times compared to transseptal approaches (n = 25). Exclusively endoscopic techniques resulted in a significant reduction in operative and room times independent of all other clinical and surgical parameters ( P < .001). Progressive use of endoscopic techniques resulted in statistically significant progressive reduction in setup time ( P = .001), operative time ( P = .04), and total room time ( P = .03) over the study period. Conclusion. The transition from transseptal transsphenoidal pituitary surgery to endoscopic techniques implies a learning process for both neurosurgeon and otolaryngologist. Despite this, a noteworthy reduction in operative times, operating room times, and room setup times is observed. The impact of endoscopic techniques on efficiency in pituitary surgery is discussed.

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Early postoperative MRI and detection of residual adenoma after transsphenoidal pituitary surgery

Journal of Neurosurgery ◽

10.3171/2019.11.jns191845 ◽

2020 ◽

pp. 1-10 ◽

Cited By ~ 2

Author(s):

Lea M. Alhilali ◽

Andrew S. Little ◽

Kevin C. J. Yuen ◽

Jae Lee ◽

Timothy K. Ho ◽

...

Keyword(s):

Tumor Growth ◽

Negative Predictive Value ◽

Predictive Value ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Residual Tumor ◽

Pituitary Surgery ◽

Intraoperative Assessment ◽

Postoperative Mri ◽

Transsphenoidal Pituitary Surgery

OBJECTIVECurrent practice guidelines recommend delayed (≥ 3 months after operation) postoperative MRI after transsphenoidal surgery for pituitary adenomas, although this practice defers obtaining important information, such as the presence of a residual adenoma, that might influence patient management during the perioperative period. In this study, the authors compared detection of residual adenomas by means of early postoperative (EPO) MRI (< 48 hours postsurgery) with both surgeon intraoperative assessment and late postoperative (LPO) MRI at 3 months.METHODSAdult patients who underwent microscopic transsphenoidal surgery for pituitary adenomas with MRI preoperatively, < 48 hours after the operation, 3 months postoperatively, and yearly for 4 years were included. The presence or absence of residual tumor was assessed intraoperatively by a single surgeon and postoperatively by 2 neuroradiologists blinded to the intraoperative assessment and other postoperative imaging studies. The presence of residual tumor was confirmed by reresection, tumor growth on imaging, or hormonal evidence. Interreader reliability was calculated at each imaging time point. Specificity, sensitivity, positive predictive value, and negative predictive value for EPO and LPO imaging and intraoperative assessment were determined.RESULTSIn total, 102 consecutive patients who underwent microscopic transsphenoidal resection of a pituitary adenoma were included. Eighteen patients (18%) had confirmed residual tumors (12 confirmed by tumor growth, 5 by surgery, and 1 by biochemical evidence of persistent disease). Interreader reliability for detecting residual tumor on EPO MRI was almost perfect (κ = 0.88) and significantly higher than that for LPO MRI (κ = 0.69, p = 0.03). EPO MRI was highly specific for residual tumor (98%), a finding similar to that for intraoperative assessment (99%, p = 0.60) and significantly higher than that for LPO MRI (81%, p < 0.001). Notably, EPO MRI was significantly more sensitive for residual tumor (100%) than both intraoperative assessment (78%, p = 0.04) and LPO MRI (78%, p = 0.04). EPO MRI had a 100% negative predictive value and was used to find 4 residual tumors that were not identified intraoperatively. Residual tumors found on EPO MRI allowed for reresection during the same hospitalization for 3 patients.CONCLUSIONSEPO MRI after transsphenoidal pituitary surgery can be reliably interpreted and has greater sensitivity for detecting residual tumor than intraoperative assessment and LPO MRI. This result challenges current guidelines stating that delayed postoperative imaging is preferable to early imaging. Pituitary surgeons should consider performing EPO MRI either in addition to or instead of delayed imaging.

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A Comparative Study of Endoscopic Versus Navigation Guided Microscopic Transsphenoidal Pituitary Surgery at Tertiary Care Centre in India

Romanian Neurosurgery ◽

10.2478/romneu-2018-0055 ◽

2018 ◽

Vol 32 (3) ◽

pp. 443-457

Author(s):

Anurag Sahu ◽

Sharad Pandey ◽

Kulwant Singh ◽

Vivek Sharma

Keyword(s):

Operative Time ◽

Tertiary Care ◽

Pituitary Surgery ◽

Controlled Study ◽

Complication Rates ◽

Care Hospital ◽

Significant Difference ◽

Transsphenoidal Pituitary Surgery ◽

Group A ◽

Group B

Abstract Introduction: The transsphenoidal route for pituitary surgery is considered the standard treatment for pituitary adenomas. The disadvantage of the smaller exposure of this route is partially compensated for by the introduction of the microscope with its coaxial illumination, stereoscopic view, adequate magnification, and microsurgical instruments. However, there are only few reports about the outcome of endonasal endoscopic transphenoidal technique. Aims & Objectives: Current study has been conducted to compare the efficacy, advantages and dis advantages of endoscopic versus navigation guided microscopic transsphenoidal Pituitary surgery. Material and methods: A controlled study was done in the department of neurosurgery, at tertiary care hospital in India, from the period of August 2012 to December 2017 prospectively. In Group A- 30 patients in whom endoscopic transnasal trans Sphenoidal pituitary surgery and in Group B - 30 patients, intraoperative neuronavigation was used. Observations and Results: Both the groups were similar in demographic variables. The most common age group of pituitary tumor patients was 30-40 years. Fourteen (46.6 %) patients in group A and fifteen (50 %) of the patients in group B had tumor volume less than 5 ml. In group A, thirteen (43%) patients had intrasellar tumors with no suprasellar extension, while in group B, fifteen (50%) patients had intrasellar tumors with no extension. Operative time was noted from incision to closure and average time taken in both the groups was compared. Twenty five (83%) cases of group A took between 2-3 hours and only four cases (13%) took more than 3 hours. While in group B, twenty (66%) cases took between 4-5 hours. This shows a significant difference by fisher extact test (p<0.001) in the operative time required in both the groups. Eighteen (60%) patients in group B had a residual volume between 1-1.5 ml while only two patients in group A had so. This difference is also significant Fischer Exact test (p<0.001). Four (13.3%) patients in group A had diabites insipidus while only half of this, i.e. two (6.6%) had so in group B. however this difference in postoperative complication rate is not statistically significant between two groups. Conclusion: The results of our study correlate with many previous studies to compare endoscopic and microscopic transsphenoidal surgery. These two approaches are equally efficacious in oncological outcomes and the complication rates are comparable.

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